NICE draft guidelines on giving birth - home birth or midwife led unit?

[KatieMumsnet]

Hi All

NICE (the National Institute of Health and Care Excellence) are in the news today with draft guidelines recommending that midwives advise mothers-to-be to opt for a midwifery-led unit (MLU) or a home birth when deciding where to give birth.

What do you think? Would these recommendations work for you? Would you still stick to a traditional hospital ward? Have you had a home birth and loved it? Or did you opt for a home birth or midwife led unit only to find out the resources weren't there?

Would be great to hear your views.

Thanks

MNHQ

lavolcan

One you have an epidural you're deemed high risk. High risk or at least higher risk of having an instrumental or even a section. Its why women with an epidural in most units will start to be given ranitidine tablets once they have an epidural. So women who are high risk shouldn't be in an MLU.

Then they should be on a ctg, they need an epidural pump. They'll quite possibly need syntocinon and a syntocinon pump. All equipment which isn't in an MLU.

As they're more likely to need syntocinon and an increased risk of an instrumental this means they're at higher risk of a pph and/or a shoulder dystocia. More reasons for not been in an MLU.

The only MLU I've worked in was an hour away from a CLU. I accept these things may be less of a concern if its in the next ward. But at the end of the day once you've got an epidural on board it ceases to be a low risk birth and should be overseen by a Dr. If you've got a Dr overseeing births in the MLU it ceases to be an MLU.

I don't know why any midwives would have forceps in their home birth kit as I am 99.9% sure that no midwives are trained or allowed to use them even in an emergency. I've never heard of it. I actually train Drs how to use forceps and even I'm not allowed to use them myself even though I can teach Regs and SHOs how to use them!

Thanks Viva for answering: I was just musing around the best way to offer assistance to woman who wants an epidural but would otherwise not be deemed a high risk. I wondered whether it was something which was 'this has always been done in the CLU' and no one had asked, 'why is it always done there?'

Hmm - how many women get told in plain English that an epidural turns them into a high risk? I am not necessarily convinced that women ask for them because something is going wrong and therefore it's more painful. I suspect our culture has rather 'sold' them - the 'why be a martyr' type of argument.

squizita - I've been on mumsnet for a LOOONG time (I name change regularly) and I haven't seen an out pouring of posts which insist that if you breath right your labour DEFINITELY won't hurt and won't be complicated. I've seen quite a lot of posts from people who've done hypnobirthing who feel it made a really positive difference to their labours and who feel it would help others have better and less complicated births. Never seen a post from anyone who insists that it's the answer to all problems in labour. People rarely talk about birth in absolutes. Same with breastfeeding. Posts telling people that they MUST breastfeed, that breastfeeding will categorically protect their baby from all illnesses, and that formula is 'evil' are rare as hens teeth. What's not at all rare are posts by people who insist that these opinions are common currency.

All the women I see asking for epidurals are definitely told the risks, that they'll have to go on a monitor, have a drip and have an increased chance of an instrumental.

I agree that women wanting an epidural doesn't mean something is going wrong at that point. But its the start of a cascade of intervention. They have to be monitored so any blips in the heart rate which might be normal and wouldn't have been picked up on are seen and acted on. They can't push as effectively so are more likely to have an instrumental and if its a failed instrumental then a section.

This is slightly off-topic but I've always wondered this, Viva. I know that I, and quite a few of my friends, asked for an epidural because we were 2-3 days into a long latent stage with very little sleep and food and we wanted the epidural more for a break than simply to get rid of the pain. I ended up with an emcs because DD was ill, but I know other women who then had forceps or ventouse, very typical interventions with an epidural. I always wonder whether the fact that the woman is exhausted because of such a long latent stage plays as much of a role in creating problems as the epidural itself? As in, I can picture if I had had a VB, I can't imagine I would have been pushing as effectively as if I'd only gone 12, 18 hours from the very start of contractions.

Everyone I know whose labour was more than about 10 hours had an epidural - I think exhaustion plays a big part.

With neither of my epidurals was I explicitly told anything about becoming high risk, having to go on a monitor/drip (obviously those things happened, but I wasn't told beforehand "if you have an epidural, these things will happen) or that it increases the chance of an instrumental delivery. I was aware of the risks due to having read about them beforehand. With both epidurals I was given a sheet of risks/side effects to read while the anaesthetist prepped everything but obviously I was so out of my mind with pain and exhaustion I didn't use the seconds between contractions to read it

Thurlow, quite possibly. Long latent phases are awful. To be honest I'm quite a fan of diamorphine for this but I know it has its critics. I do find that women tend to be able to doze/sleep and when stronger labour starts they're more energised.

But Quite a few first time mums will end up with an instrumental regardless of epidural.

I haven't seen an out pouring of posts which insist that if you breath right your labour DEFINITELY won't hurt and won't be complicated

I said a mouthy minority of women weigh in on internet forums and MN give them short shrift. Elsewhere it is more frequent. But they do come up so some people do think this! Unfortunately if reality TV has taught us anything it's that the loud 'shock' opinions stick out more than the more balanced majority.

One I can remember off the top of my head from MN was called 'birth advice' or something similar. As I said, she got told well and truly no.
There was another legitimate thread about 'breathing out' non-pushing childbirth where, among sensible replies a few people suggested childbirth doesn't hurt- again they were addressed.
Not to mention the unhelpful 'rhetorical question' in a previous post here, totally out of kilter with the rest of the discussion.

I've also noticed sadly when people notice these, others say "oh nonono no one does that!" as if their existence is imaginary or counters actual proper discussion. It doesn't, because their point is actually the opposite of those who want better care: they think there's a one-fits-all easy solution and blame women who don't fit it (just happens their version seems natural on the surface).

Thanks Viva. I know that is probably something that you just can't measure by statistics, but it always struck me as a possibility. I know I was completely out of it with exhaustion and it would have been 48 hours with no sleep and throwing up every hour, when they said I was having an emcs I was so unsurprised because all I was thinking was "thank Christ, I couldn't push if you paid me right now"

Can diamorphine be given before you are 4cm? This came up on another thread the other day. I suppose it can't be but anything to get through a long latent stage.

...the BFing one is a quote from a thread which was on chat or AIBU I believe. It literally said that. With lots of exclamation marks.

I think you're thinking of whole threads: it's never a whole thread. It's a post on a normal thread dotted here and there.

Shouldbemumof2 that is awful, I am so so sorry.

Personally I was convinced by my mw to go for a home birth and after a lot of thought we decided to go for it. It was absolutely fantastic and a wonderful experience. IAm a first time mum and a health care professional so whilst I knew it would be likely we may have to transfer to hospital, I was reassured by reading the literature on home birth and was able to make an informed decision to have one.

Our local service is under pressure but It was very straight forward for us. There was never ever any talk of one not being available if we wanted it and it was made very clear to is that we could change our mind up until the minute the baby popped out. We had the same midwife do all our ante and post natal care and she also delivered our baby. Can't ask for better continuity of care than that.

There really is nothing like crawling back into your own bed after giving birth whilst your partner brings you tea and cake and a midwife cleans your bathroom for you.

I feel truly blessed to have had such a great experience. Even if it hurt like hell.

Here's a relatively 'naice' example: OK, not about home birth. But majority of people saying you have limited influence over things, one person insisting it was because they did it properly. www.mumsnet.com/Talk/childbirth/2028618-A-little-advice-from-a-brand-new-mum-Happy-birth

I'm going to a MLU in a neighbouring trust after my experience with a CLU. To be honest, I'm not sure who was who in my first labour in the CLU, but after an hour of pushing, they buzzed someone senior, he came in, gave me episiotomy and ventouse.

The MLU I've picked said the average transfer time is 5 minutes. It's on a different floor of the CLU in the same building. I'm not sure what it meant in practice. But I'm sure they took at least 5 minutes to get the 'consultant' for me last time anyway.

Thurlow, it can be given prior before 4cm but its a grey area about whether it should be prescribed by a Dr or not. A midwife can give it to a labouring woman without a prescription.

Drs may be reluctant to prescribe it as it has an accumulative effect on the baby. Many hospitals will also have a policy that anyone who needs it should be on the labour ward as it can have a respiratory depression effect on the mum. So it can depend how limited space is on the labour ward.

And to those that says 'sod it, I want an epidural after 40 hours'. I wasn't given one in a CLU. They won't even give me gas and air. I was left totally alone with my DH because they were short staffed. The staff I saw most was the coffee lady.

That's the reason I would never go back again.

.....they were short staffed. The staff I saw most was the coffee lady.

And that makes a mockery of the 'I want to be in hospital in case it goes wrong' type of argument. If there is no one to attend you it doesn't matter how wonderful they would be if they were there or how well equipped the hospital is. David Cameron I recall promised 3000 more midwives before he was PM. He quickly backtracked on that one.

Squizita, that example you give is a first time mum on a high after a good birth, giving her opinion - which is 'be wary about using pain relief'. The next post is from someone saying 'you shouldn't tell people not to use pain relief (which she didn't do), and on it goes, slapping her down.

:-(

That's terrible, toddling.

Lemiserable: I thought they were very harsh to that poster.

There was another one who said episiotomies are not all that bad. What I think she was trying to say was that she had one, it wasn't as bad as she expected and yours might not be either. By golly, was she torn to shreds by others, just because she didn't express herself all that well. I think she didn't post again and I am not surprised.

She uses modals like 'should', 'must' etc' - OK, she does it 'on a high' but I wanted a nicer example, not the troll who pops up with one nasty comment among 100 nicer ones. Please tell me you're getting that I am NOT saying lots of women hold extreme views, or that extreme views are in any way connected with either side of the debate... I'm saying the opposite. That there is a core minority who make many women feel awful, and ignore the issue of care-for-women by their obsession that there's a magic solution.

...TBH I am confused by how aghast and insistent you are that internet extremists (who we all know exist) are imaginary when it comes to birth and parenting.
Why would their existence affect the validity of everything you've been saying (much of which I have been agreeing with)?
But their existence does frighten and upset women. You see ONE comment and think 'meh, nutter', someone else sees it and feels really down.

There was a guest post about BFing last year: 14 pages of 100s of reasonable women, one who upset everyone else. She exists! She's ONE... but who will stick in the mind.
Saying whether she was pro or anti BF is actually moot point - the point is again it came down to 'do as I do' not 'care givers should be doing their job'.

Squizita - you came across on that thread as very righteous - desperate to put down someone who dared to think they'd learned something about birth from their own experience. She was 2 days postnatal and her post was absolutely to be taken at face value. Instead, loads of people with issues about their births piled on to the thread to let her know that she needed to be more 'humble' with her opinions. It was gross.

If she'd come on and said TAKE THE DRUGS! I doubt one person would have given her a lecture on undermining other women and lecturing them on how to give birth

I don't think internet extremists are imaginary - I just give them no attention at all in the same way I give no brain space to people who say the moon is flat. Everyone who's got two brain cells to rub together knows that birth is very, very variable and that sometimes things get beyond any sort of control at all. If someone is trotting out opinions like 'hypnobirthing will guarantee a good labour' or a homebirth will guarantee a straightforward delivery' I switch off, as I assume they're either 12 or completely mad. I certainly don't take their words as being representative of serious and widely held opinion, and I would bother to challenge it. It's bollocks and anyone who's got any sense pays no attention to it at all.

If she'd come on and said TAKE THE DRUGS! I doubt one person would have given her a lecture......

Ditto Lemiserable about homebirths (which is not unrelated to this thread). It's only a matter of time before someone comes on to say that they would have died if they had had a home birth, with the implication being that therefore no one should have one. There is usually neither not a word about whether the management of the labour help cause the problem nor since you are not them, what happened to them might never happen to you.

Though on reflection there would be one person saying 'don't take the drugs' and she would be shouted down.

...Perhaps they would if she's said you should take the drugs. Apologies if I can across badly, however to be fair, quite a few people were extremely vehement and shouty on there, I was just trying to respond to why that might be 'logical' way not all hyper like some (you'll note I comment after them, purely about why people were taking it that way, based on the language used).

I really don't want to get in a row over this. OK, that was a bad example, I just did a quick search of old threads I'd seen and this was on there.
Clearly you don't feel that there are people out there who say how things 'should' be done and wonder why people seem paranoid about . I do.

I don't think this actually has anything to do with standards of care, HB, MLU, CLU. It's more why discussions get all muddied up.
You get a small number of people (or ranty newspapers) saying "you shouldn't do xyz or expect it to go wrong" (whether they're referring to HB or CLU) and it gets conflated with the true situation, which is that xyz is woefully underfunded/misunderstood/hard to get/has bad staff/a poor ethos etc'.

And then....no one tries to make it better for everyone else, easier to just say it's how it is.

I think the government penny pinchers must secretly love the ranters: home births are very hard to get and the midwives stretched, CLUs will get you a scalpel-happy jnr dr interfering... no need to ask why the hell is this? it's just the way it is.

It happens with everything in the public sector IMO, they rely on moral panics to hide from the true issue.